A sleuth story Patricia Cornwall would appreciate

Microbes, a Pharmacy Clean Room, Waste Bins, ATP, and a keen-eyed pharmacist

Recently I was part of a trio who presented an intriguing case-study of a microbiological contamination issue in a pharmacy clean room – it took months to solve, and ATP proved an excellent tool.

Tyler Weaver, Josh Guinter (Children’s Hospital of Philadelphia) and I delivered our paper entitled “Resolving microbial contamination of reusable waste bins in a pharmacy clean-room” at the Sept Association for the Healthcare Environment (AHE) conference in Pittsburg PA.

We are soon to publish – in meantime click here to view our PowerPoint presentation.

The story in a nutshell…

  Within a hospital, a Pharmacy Clean Room (PCR) is where sterile medications are prepared for patients – it is an “inner sanctum” with restricted access and is regularly tested for microbes to ensure all surfaces are scrupulously decontaminated to an ISO Standard – at a level higher than operating rooms.

A recent failure in a PCR resulted in 753 patients being infected with 64 deaths across 20 USA states.

The problem

  • PCR work-surfaces are required to be regularly tested for microbes. Two tests in PCR exceeded allowable level – triggering immediate action
  • Surfaces and ducts were scrupulously cleaned – but tests failed a second time. Several weeks of investigations proceeded
  • Then a keen-eyed pharmacist noticed a gown-tie moving as it hung from a waste bin in the PCR
  • Tie-movement meant air-flow; airflow meant bugs could waft in air – perhaps bin was source?
  • The reusable bins were tested, found to have very high microbial counts, and bin-vendor A was asked to remedy

The remedy

  • Microbe tests are expensive, so bins were ATP-tested as surrogate (ATP detects microbes and other living cells)
  • Bin-vendor A could not reduce ATP count to target-level  of <250 Relative Light Units (RLU) – aver of highest counts was 14,844 RLU
  • Second vendor (Vendor B) supplied bins for testing – all passed – aver of highest counts was 103 RLU – hospital changed to Vendor B for PCR.
  • No further PCR work-surface tests failed.

The explanation

  • Vendor A supplied bins “nested”. Entrapped moisture in bottom bin enabled microbial growth
  • When pushed into bin, discarded gowns created “piston effect” liberating microbial aerosol which wafted onto PCR work-surface
  • Vendor B wash process had higher level of bin decontamination. Bins supplied individually, not nested.
  • In 4 years: bins have exceeded ATP threshold of 250 RLU occasionally, and none since Aug 2015; no failures in PCR work-surface microbe tests have occurred.

Take Home Messages

  • Vendors of reusable bins have differing wash, drying  and delivery processes. Ask for details of processes and ATP-test (particularly if for PCR use).
  • ATP testing using a threshold of 250 RLU is a useful adjunct for checking QA of external waste bins used in PCR

Zika: update on geography, precautions and sexual transmission

Last Friday I stated Zika was in theory capable of sexual spread, and on Tues Feb 2nd, the Texas Dept State Health Services confirmed a sexually transmitted case.

Prior to the Texas announcement only one sexually transmitted case had been confirmed – Foy et al in 2011 published a case in the wife of a Zika researcher returning to Colorado in 2008. Subsequently, Musso et al in 2013 found Zika in the semen of an infected Tahitian male.

Notwithstanding the above, CDC confirm transmission is primarily via mosquitoes (Aedes – they also transmit dengue, but not malaria), and rarely, to the foetus from infected mothers.

Zika is a mild disease, predominantly with no symptoms, but with 4,800 cases of microcephaly in Brazilian babies in the last 18 months, this aspect, and the rapidity of spread of the disease (up to 1.4 million cases in Brazil in 2015) caused WHO on Monday to classify ZIKA as a Public Health Emergency of International Concern (PHEIC).

By classifying Zika as a PHEIC, WHO mobilizes internationally the resources for research and action into the disease, its sequelae, and its prevention.

WHO state there should not be travel or trade restrictions with any Zika-active country and CDC state prevention is via classic anti-mosquito measures and have issued cautionary travel advice for pregnant females

The US has the relevant Zika Aedes species in the lower states and as yet mosquito-transmission has not been documented but, with returning travelers, there is the possibility of local Zika transmission

But if Zika was first discovered in Uganda monkeys in 1947 (first human case in 1952), then appeared in the Pacific in 2007 with the first major epidemic being in French Polynesia in 2013, how did it suddenly explode in Brazil? It was not the Brazil World Cup as originally thought. Musso examined the “fingerprint” of Zika isolates in infected countries and determined that during 2013-14:

  • The origin of introduction to French Polynesia is unknown
  • New Caledonia was infected from infected travelers returning from French Polynesia
  • French Polynesians brought the virus to Easter Island when attending the island’s Tapati Festival in early 2014
  • Other nearby Pacific countries were infected because inter-travel is common
  • In Aug 2014, teams from several of the above Pacific countries attended the World Canoe Championships in Rio de Janeiro. Musso suggests this introduced Zika to Brazil.

Now, in just 18 months, 28 countries have active Zika transmission.

Fortunately for New Zealand (where I live) the Ministry of Health state the subspecies of Aedes has not been found. But returning travelers with symptoms might need heed the Texas news. And spread via an accidental needlestick to an attending healthcare worker, although as yet undocumented, must also be a concern.

WHO prioritises world Epidemic Threats

A panel of experts met at WHO Geneva this week to prioritise the top five to ten emerging pathogens likely to cause severe outbreaks in the near future, and for which few or no medical countermeasures exist.

These diseases are a blueprint for R&D preparedness to help control potential future outbreaks.

The initial list, to be reviewed annually, comprises:

Three other diseases were designated as ‘serious’, requiring action by WHO to promote R&D as soon as possible; these were chikungunya, severe fever with thrombocytopaenia syndrome, and Zika.

Other diseases with epidemic potential – such as HIV/AIDSTuberculosisMalaria,Avian influenza and Dengue – were not included in the list because there are major disease control and research networks for these infections, and an existing pipeline for improved interventions.

A shared syringe – and $80mill bill

With social media and education outreach, major outbreaks of Bloodborne Pathogens (BBP) should be a thing of the past. Not so.

Alarm bells rang when 11 new HIV cases occurred in Nov-Jan in a small Indiana community – double that normally seen in a year .

This “handful of cases” from shared syringes among opioid drug users, had grown to 26 cases when reported in Feb by the Indiana State Department of Health, and by March had grown to 79 cases. By April the number had risen to 135 cases, 84% of whom were coinfected with HCV.

In a US CDC-Medscape Expert Commentary released this week, the number is now at 170 HIV cases, almost all HCV coinfected. The article states, “The lifelong medical care costs alone for treating the persons …will be more than $80 million“.

WHO in 2004 examined the alarming increase in BBP transmission among drug injectors and after a review of over 200 publications concluded that: the evidence for BBP reduction with needle and syringe exchange programs (NSEP) was overwhelming; NSEP need be country-wide; and any contrary legislation needs be repealed.

PS. Proudly, Australia and New Zealand were two of the first countries to use NSEPs nationally – and now via vending machines!

Interestingly, USA banned federal funding of NSEP in 1988, removed the ban in 2009, and reinstated the ban in 2011 (the legislation does not ban NSEPs; just federal funding of them). Opponents of federal support for NSEPs argue that it signals governmental acceptance of, and would facilitate the uptake of, illegal drug use. WHO says not so. Thankfully, in 2011, at least 221 non federal NSEPs operated in the US.

CDC recommends drug injectors be referred to “programs that provide access to sterile injection equipment.” A wise, evidence-based recommendation.

PS. Sign up below to receive email alerts whenever I publish a new post – I’ll never abuse your privacy.

Travel history is essential – not just for Ebola

There are many lethal, more frequently occurring diseases than Ebola, entering our countries.

Recently, on the chat room of USA Assoc. for Professionals in Infection Control & Epidem (APIC), members have asked how much longer hospitals should ask patients about overseas travel (to alert staff for Ebola).

Malaria is another reason why travel history must CONTINUE to be sought.

Several decades ago as a Malariologist in a developing country, I strove to remind colleagues in developed countries to ALWAYS ask a travel history when any patient presented with fever, chills or headache (FC&H). I have seen a patient walk in unassisted with FC&H at 5pm, and die from P. falciparum cerebral malaria at midnight.

The deaths of two tourists from cerebral malaria in a Springfield Missouri motel last month shows how rapidly and insidiously this disease can kill travelers. And underpins why travel history is essential if patients present with fever to an emergency dept.

In 2011 USA hit an all-time high with nearly 2,000 cases of malaria being diagnosed in travellers.  In 2012 1,687 cases of Malaria were diagnosed in USA, with 1,683 (99.8%) occurring in travelers. Six of the cases died.

Ebola pales into the background in the face of other imported diseases for which a travel history is needed for diagnosis.

 

Sierra Leone Ebola surge – curfew needed

You probably noted my excitement, after I returned from Sierra Leone, when a week of “zero” days occurred in early May. However recently in Port Loko and Kambia cases have surged and the President has declared a 21 day dusk-to-dawn curfew in these districts.

The graph below (compiled from Ministry Reports) shows why the decree was issued – cases had fluctuated from 0 to 2 per day, but in the last two weeks, 5 cases were reported in one day, then 9 on another, all from the two districts. 15 cases in one week is the highest since March.
Picture of graph
Of the recent cases some have occurred in individuals unlinked to known cases, and others in areas  free of cases for over 40 days – two signs of loosening of behaviours. The good news is that the previous “hotspot”, Freetown Western Urban, had zero cases – the first time in 10 months.

WHO in their latest summary, said the decline had “stalled”. I feel sad for the people of the two curfew districts – and for the contact tracers – and all aid workers and national staff arduously trying to reach zero.

Hopefully in this Ebola warzone, the curfew is the last offence needed to win the battle.

 

PS. I you’d like an email alert of new posts – register at bottom. I will never abuse your privacy

Handling New Zealand’s 1st Ebola suspect- excellent test of smooth planning

There is no substitute for repeated, detailed practice.

Ruth Barratt’s Open Access Case Report this week in Healthcare Infection is testimony to thorough planning and training, with the “real run” showing improvements can still be made.
The Report is a clear expose of the importance of Infection Prevention and Control and the availability, use, suitability and shortfalls of Personal Protective Equipment (PPE).
Having returned from Sierra Leone, I can confirm Barratt’s “real-life” is “real-life”. Her emphasis on the necessity of preparedness through practice drills, reflects that required in Ebola Red Zones.
Other mirrorings they found were:
• Staff preferring certain PPE over others (WHO state gown+hood vs coverall is personal choice – there is no evidence one is safer over other, and staff may find gown safer through familiarity, and, in certain cultures, more gender-acceptable);
• Fogging of eye-protection (CDC now recommends face-shields over goggles and many Red Zone staff leave face-shield bottoms outside their hood). Some Ebola Red Zones rub toothpaste on inside of lenses as a defogger (an old SCUBA-diving technique);
• Swapping thick outer gloves for long-cuff surgical outer gloves aids dexterity – others agree;
• Locating in-country sources for preferred PPE;
• Some PPE items being too small for taller/larger staff;
• Gowns not lasting (UNICEF recently published recommended product-specifications for PPE).

The author stressed the importance of having a trained observer in addition to a “buddy”. In Ebola Red Zones such observers are called “hygienists” and their calm, talking-through of each PPE-removal step is considered a God-send by near-exhausted staff.

The patient (who proved Ebola negative) was an Ebola-trained nurse – and assisted the staff with some of her own care and gave feedback on their procedures!

NB. If you would like to receive “New Post Alerts” via email – sign up below. I won’t share with anyone!

Two new ways to combat antibiotic resistance

Timely dosing and a body wash may help

Antibiotic resistance is not new – resistance genes have been found in 700 year old faeces!

But WHO state resistance is a major issue in healthcare today. In their Policy Paper, Ontario Medical Association state that antibiotic resistance results in infections being more severe, of longer duration and higher mortality, as well as longer hospital stays and more aggressive treatments with expensive “third-line” antibiotics. This means increased healthcare costs.

Judicious antibiotic use and banning of antibiotics as growth-enhancers in animals are essential. But additional measures are needed.

One new proposal is to change the timing of antibiotic dosing. In a recent paper, Meredith et al used computer modelling to determine that the timing of dose, relative to a bacteria’s recovery, may allow the bacteria to be killed before its production of beta-lactamase can begin.  If successful, it means first-line “old fashioned” antibiotics can still be used.

At last week’s SHEA meeting, a second novel method was proposed. McKinnell et al showed chlorhexidine (CHX) body wash can reduce colonization with MRSA. Compared to MRSA ‘Contact isolation’, they found CHX had fewer MRSA contamination events. Also, the authors argued that CHX use may result in a higher quality of care compared to isolation.

In another life (almost 40 years ago!), I researched the effect of whole-body CHX bathing on the normal flora of patients pre-operatively and concluded in a book chapter, “The course that is apparent is a return to the early concept of ‘total body’ reduction of Staphylococcus aureus carriage..” Goes to show – if you live long enough…:)

Sierra Leone – helping rebuild the local school

Walking by the local village, angelic children’s voices singing “ABCDEFG” enticed me to a dilapidated hut.

 First visit Through the broken doors I saw a room with about  30 children – who immediately stood and chanted in perfect unison, “Good afternoon sir“. I don’t know who had the biggest grin, the children or me!
Pre - rebuild I’d passed the small hut many times and never knew it was a school. It is voluntary, and Bailor and assistant-teacher Mustapha, unpaid. Classes are conducted six days a week from 3-6pm and on Saturdays they ask a 1,000 Leones (20 cents) “fee” from those who can afford it. few attend on Saturday.

In an impromptu geography quiz (“Where do you think I come from”), I noticed they had no map so my wife Jenny and I bought books, pencils etc and a large wall atlas – the children recognized Africa, and pointed to Sierra Leone – but couldn’t quite fathom New Zealand’s distance. And couldn’t believe NZ had fewer people than their country.

The school, originally built by a UN peacekeeping contingent from Mongolia in 2008, was in a poor state and on one of my visits Bailor gently asked could we help fund the repair of the leaking school. I suggested he obtain a quote and Momoh Sesay the village Chairperson, upon hearing this, took the lead. Momoh is an engineer, (unemployed since Ebola – as were most in the village) and next day he had a detailed written quote for me – $900! Low, because he would use the unemployed builders, painter and artist in the village.

I mentioned the project to WHO colleagues and without exception, all donated and raised the $900. After giving Momoh Sesay and the teachers the go-ahead, the village was soon abuzz. Leaving the following Wednesday, I was sad not to be able see the project finished . No problem they said “We’ll start tomorrow and finish it before you go“.

All hands on deck  Children painted

They started that Friday 8am and worked 5 days straight including Sunday, (“God will forgive us for not attending church”). At one stage I counted 15 men, women and paint-covered children lending a hand – the village was proudly rebuilding their own school.

Saving the animals    New animals

I suggested we preserve the Mongolian’s original painted animals (a panda, two lions and Pooh Bear) so I borrowed a hacksaw blade from my hotel and showed some helpers how to cut out the animals from the original plywood walls – by day’s end they had all four neatly cut out and edges sanded. The village artist bought paints and restored each animal to its former glory and attached them to the new walls – big smiles abounded! And he skillfully painted a sign acknowledging the WHO Ebola response team’s donation.

School completed

The finished school was fitted with mosquito netting all round and we had a grand opening Tuesday evening!

Momoh Sesay’s wife, Aisha, cooked all day and WHO staff and villagers reveled in the grand opening party. Aisha is Head of the nearby Dance Academy (they’ve performed nationally and internationally but had only had 2 engagements since Ebola) and she brought her dancers and drummers and “Rubberman”, the troupe’s contortionist – and the dusty street was transformed into a festive stage.

Rubberman on stool

Village gathered   Children performing v2

Hinta 1 - group at opening

What a profound, humbling, once-in-a-lifetime experience.

Rare Bubonic Plague outbreak from pet dog – and possible human transmission

Two exceptions to the rule – bubonic plague not from rat fleas, but from a pet dog; and possible human to human transmission – the first in USA in 90 years.

As a former laboratory manager I was mindful of the “rare ones” i.e. identifying diseases that are exotic or rarely seen – or more importantly, missing the diagnosis. More so if the disease is communicable.

In a recent CDC MMWR, Runfola, House, Miller, et al. published such an event occurring in Colorado.

The index patient was admitted to hospital ill with fever and cough, worsening to pneumonia. A lab culture automatedly misidentified the pathogen as Pseudomonas luteola but as the patient’s condition worsened, the culture was sent to the state lab and correctly identified as Yersinia pestis, the cause of bubonic plague.

Investigation revealed the dog had recently died, and three persons who had contact with the dog were found to be ill, two with pneumonia. One of the three had contact with the index patient and human to human transmission could not be ruled out. Two of the cases were veterinary employees who euthanized the ill dog.

In total, 114 people were investigated as they had contact with the dog or the index patient. No other cases were detected and the four patients recovered with appropriate therapy.

Untreated Bubonic plague (the “Black Death”) can be fatal in 93% of cases and although the initial laboratory misidentification resulted in occult exposure to numerous healthcare workers, an astute physician and rapid investigation resulted in zero fatalities in this outbreak.

The lesson: double-check organism identification if patient has plague-like symptoms (this is third time Y. pestis has been mistaken for P. luteola).

 

PS. I returned home this week from Sierra Leone and will write an “update” post asap.